Laserfiche WebLink
SECRET SIDEWALK TATTOOS <br />MEDICAL HISTORY <br />Name: Date:___/� <br />Date of Birth:Female Male Other <br />Emergency Contact- Name: Phone Number: <br />I up 5F.W.01 50) of IDES) 'R."WINEW1101 03 10 <br />HEPATITIS <br />HERPES <br />HIV/AIDS <br />EPILEPSY/SEIZURE DISORDER <br />DIABETES <br />SCARRING/KELOIDING <br />BLOOD THINNERS <br />PREGNANCY/NURSING <br />FAINTING OR DIZZINESS <br />DO YOU NEED TO BE PREMEDICATED <br />PRIOR TO SURGERY OR DENTAL <br />PROCEDURE? <br />T.B <br />HISTORY OF HERPES INFECTION AT <br />THE PROCEDURE SITE? <br />ASTHMA <br />HISTORY OF HEMOPHILIA OR OTHER <br />BLEEDING DISORDERS? <br />ALLERGIC REACTION TO LATEX <br />OTHER: <br />ALLERGIC REACTION TO ANTIBIOTICS <br />ECZEMA/PSORIASIS <br />SKIN CONDITION <br />HISTORY OF CARDIAC VALVE DISEASE <br />HEART CONDITION <br />HEMOPHILIA <br />Other risk factors for blood borne <br />pathogens? <br />